Let's go on to a case.
A 48 year old female complains of a
tingling sensation in her fingertips
as well as the skin around of her
mouth which woke her from sleep.
She is on the post-operative floor and she's just undergone
a complete thyroidectomy for papillary thyroid cancer.
Her temperature's 37 degrees celsius, her
respirations are 15 breaths per minute,
her pulse rate is 67 beats per
minute and a blood pressure 122/88
While recording the blood pressure, spasm of the muscles
of the hand and forearm is seen as shown in the image.
A 12-lead EKG also reveals a prolonged QT-interval.
What is the next best step in
the management of this patient?
In reviewing this presentation, this
patient has just had thyroid surgery
and is now manifesting the classic
symptoms of hypocalcemia.
On physical exam, she has Trosseau's
sign and prolonged QTc interval.
In hypocalcemia, one of the
classic manifestations on EKG
is the prolongation in the distance between
the Q wave and the T wave on the EKG
This is known as the QT interval and in
this clinical setting, is significant
because it implies that the
patient's calcium level is very low
This patient has acute hypoparathyroidism and the calcium
and parathyroid hormone level should be checked.
This will confirm the diagnosis and the patient
should have immediate supplementation of calcium.
Calcium should be replaced in this patient as they're
exhibiting signs of hypercalcemia following total thyroidectomy
All four parathyroid glands are
rarely removed during thyroid surgery.
Unfortunately, when it does occur,
results in hypoparathyroidism.
Lifelong calcium supplementation is
usually required for these patients.
It can occur in the Hungry bone syndrome.
This occurs when patients have surgery for
hyperparathyroidism and undergo a parathyroidectomy
and as a consequence of the bones being deprived
of calcium for a prolonged period of time
because the patient has
the post operative phase can manifest
with severe reductions in serum calcium
as the bones reabsorb calcium
from the circulation.
The most common cause of iatrogenic hypoparathyroidism
is inadvertent injury during anterior neck surgery
like a thyroidectomy or a parathyroidectomy, both
of which present within a few hours of surgery.
Depending upon the extent of injury or resection,
surgical hypoparathyroidism may last days to weeks.
Permanent hypoparathyroidism when it is complete,
there is an undetectable serum PTH level
and a higher prevalence
of a hyperphosphatemia.
In a partial parathyroidectomy where
there is still some gland remaining,
inappropriately normal PTH levels may
be found with concurrent hypocalcemia.